In this situation, can the routine preanesthetic evaluation be shortened in order to minimize troubling the child? Is a physical exam necessary other than observation? Are preanesthetic vital signs necessary?

Would you prefer that the child receive his usual morning dose of risperidone?

What premedication would you choose? Why?

What is your induction plan?

What are your plans for maintenance of general anesthesia?

The dentist performs two extractions and there is some bleeding, controlled with pressure. She does not think overnight admission is indicated for the child. Once the case is completed, how will you manage emergence from anesthesia?

In the PACU, he immediately pulls out his IV. What would be safe post-op analgesia for the child?

Autism disorder (AD), or autism, is the most common pervasive developmental disorder (PDD) with a recently estimated prevalence of 13 per 10,000. The etiology of AD is still unknown, although genetic factors are probably involved, and in 5–10 % of cases, there is an identifiable associated known medical condition. The onset of autism disorder has been set at before the age of 3 years, and other autism spectrum disorders (ASDs) may have a later onset. The prevalence of Asperger’s disorder is approximately 3 per 10,000, and childhood disintegrative disorder is very rare, estimated at 0.2 per 10,000. Rett disorder prevalence is 1 per 15,000. The prevalence of all PDDs in recent surveys is about 60 per 10,000. Behavioral disturbances are fairly common in these disorders and are very often challenging to treat. Tantrums, aggressive behavior, and overactivity/hyperactivity are frequent from the early phases and may last throughout adulthood, causing serious problems in adaptation. The severity and the development of the various symptoms and their clinical features vary on an individual basis [1].

Records from the primary pediatrician are sufficient for the preanesthetic visit. The vital signs obtained with the child resisting and struggling will not reflect his usual state of health in any case. If these records are not available, it still may not be useful to restrain the child and force him to have BP, HR, and RR documented. With patience and engaging in play with the child, it may be possible to obtain an oximeter measurement.

Risperidone is generally given BID. Unless this presents an excessive burden to the family, usually the morning dose should be given to the child.

Moderate efficacy and safety of risperidone for treating maladaptive behaviors, including aggression, hyperactivity, self-injury, and irritability, have been documented in the available studies. Two studies also found some degree of improvement in some of the core features of ASD. Risperidone was promising in preschoolers with ASD also combined with behavioral interventions. Efficacy and tolerability of risperidone in the various types of PDDs, including the different degrees of core symptoms, from mild to severe, are still undetermined and should be appropriately addressed. At present much caution is therefore warranted in this vulnerable population that raises additional concerns and that needs continuous care, especially when receiving pharmacotherapy [1].

Risperidone doses varied from 0.1 to 0.5 mg/day, and all the studies started with low doses that were increased slowly. The initial dose was 0.25–0.5 mg/day once or twice daily, with increments of 0.25 mg or 0.5 every 3–7 days until a therapeutic response was reached. Therefore, a flexible schedule of dosing is advisable to coincide with characteristics of the child and to minimize unwanted side effects.

The Cochrane database review reported possible benefit but noted the generally limited amount of data [2].

Weight gain was the most frequent adverse event, ranging from 1 to 10 kg. Weight increase usually stabilizes over time, but it is more pronounced during the first 2–3 months of therapy. Several potential long-term health risks arise with weight gain, such as hypertension, heart disease, diabetes, and dyslipidemia. Sedation is another common side effect, but in most studies, it is usually referred to as transient [1].

The US Food and Drug Administration (FDA) has approved risperidone and aripiprazole for treatment of irritability associated with autism in children and adolescents. Despite their efficacy, the use of these medications is limited by their side effects. In individuals with severe irritability, the first-line treatment is often risperidone. Because of its relatively lower risk of weight gain and metabolic side effects, aripiprazole may be used initially if there is a personal or family history of obesity or diabetes. Monitoring of body mass index and metabolic profiles is indicated with both medications [3].